Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to improper payment (not to mention, an injustice to the patient). The next thing you know, the claim fails a Risk Adjustment Data Validation (RADV) or Office ...
To assign an appropriate diagnosis related group (DRG), you must correctly identify present on admission (POA) indicators on all inpatient claims for services rendered in general acute care hospitals. This may be challenging if there are documentation deficiencies in the medical record. Here’s how to remedy those deficiencies. POA Review POA is defined as conditions ...
Value-based care models rely heavily on provider documentation to illustrate clinical quality as the basis for reimbursement. The Certified Documentation Expert Outpatient (CDEO®) credential is an excellent way for coding professionals to validate their essential role in documentation improvement to practices, hospital systems, and payers. Although AAPC designates the credentialed title as “Certif...
Healthcare expenditures account for an estimated 18 percent of the United States’ gross domestic product. A 2014 BMC Health Services Research study (“Billing and Insurance-related Administrative Costs in United States’ Health Care”) found that in 2012 billing and insurance-related administrative costs alone totaled $471 billion — nearly one-fifth of all healthcare costs. While I celebrate ...
Documentation must meet certain conditions for you to consider time as the key factor for the E/M level. Most evaluation and management (E/M) services are coded based the level of history, exam, and medical-decision-making documented by the provider. But when the provider spends more time counseling and coordinating a patient’s care than anything else, using ...